72 hour post admission audit

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Pre-admission

• PA1-1<br>Have you entered the first name and last name of the resident whose personal plan you are auditing into the comments box?

  Yes

  No

  N/A

• PA1-2<br>Was a pre-admission assessment completed prior to the resident moving into the home? (e.g. check date of admission is not before the pre-assessment was completed)

  Yes

  No

  N/A

• PA1-3<br>Has the pre-admission assessment been completed in full and signed by the Home Manager evidencing that the home can meet the residents needs?

  Yes

  No

  N/A

• PA1-4<br>Was the 'Dependency Assessment' completed at pre-admission and reviewed on admission?

  Yes

  No

  N/A

Upon Admission - General

• PA2-1<br>Has the resident been added to resident admission book?

  Yes

  No

  N/A

• PA2-2<br>Has the resident been registered with a GP?

  Yes

  No

  N/A

• PA2-3<br>Has the 'This is Me' document been completed in full?

  Yes

  No

  N/A

Risk Assessments

• PA3-1<br>If there is a DNACPR in place, is it current (check expiry date), original and held at the front of the file?

  Yes

  No

  N/A

• PA3-2<br>For every identified individual risk to this resident was there a support plan and individual risk assessment in place? (e.g. if a resident is at high risk of choking / aspiration as determined by the choking assessment then there will be an eating and drinking support plan in place supported by an individual risk assessment detailing how the risk will be managed.)

  Yes

  No

  N/A

Monitoring folder and daily notes

• PA4-1<br>Does the resident have their own 'Grab file' which has been checked to ensure it contains the following: DNAR/RESPECT document if applicable, copy of MAR, hospital passport, support plan, this is me and any other relevant information needed in case of an emergency?

  Yes

  No

  N/A

• PA4-2<br>Do the daily notes give a clear indication of the support provided to the resident since admission? (As a minimum there should be one entry per shift (Early, late and night) but best practice is to record support as it is given)

  Yes

  No

  N/A

• PA4-3<br>Were daily notes records started on the day of admission?

  Yes

  No

  N/A

Baseline checks

• PA5-1<br>Have baseline observations been recorded (if applicable)

  Yes

  No

  N/A

• PA5-2<br>Has the body map been completed in full upon admission?

  Yes

  No

  N/A

Support with mobility

• PA6-1<br>Has the 'Moving and Handling' risk assessment has been completed in full?

  Yes

  No

  N/A

• PA6-2<br>Has the Falls screening risk assessment been completed in full?

  Yes

  No

  N/A

• PA6-3<br>Does the resident's Mobility and falls support plan clearly state their mobility and falls prevention support needs and how best to support the resident to maintain mobility and independence? (Plan should reflect how to support person with all appropriate equipment and clearly indicate what a person can do for themselves and when they may require staff support, the plan should accurately reflect their current level of risk, ensure plan reflects any falls investigation outcomes)

  Yes

  No

  N/A

Support with skin integrity

• PA7-1<br>Has the Waterlow risk assessment tool been completed accurately?

  Yes

  No

  N/A

• PA7-2<br>Is there a Skin support plan in place?

  Yes

  No

  N/A

• PA7-3<br>Is there a wound care plan and assessment in place along with photograph? (If applicable)

  Yes

  No

  N/A

Support with eating and drinking

• PA8-1<br>Has the 'Nutritional tool' been completed?

  Yes

  No

  N/A

• PA8-2<br>Has the MUST screening tool been completed in full?

  Yes

  No

  N/A

• PA8-3<br>Has Residents weight and BMI been calculated and any risk identified included in the care plan and risk management?

  Yes

  No

  N/A

• PA8-4<br>Has the Prevention of Choking risk assessment been completed accurately?

  Yes

  No

  N/A

• PA8-5<br>Is there a Nutrition and Hydration support plan in place?

  Yes

  No

  N/A

Support with oral hygiene and personal care

• PA9-1<br>Was the 'Oral Hygiene assessment' completed in full?

  Yes

  No

  N/A

• PA9-2<br>Is there a 'Personal and Oral Care' support plan in place?

  Yes

  No

  N/A

Support with continence needs

• PA10-1<br>Was the 'Continence' assessment been completed in full?

  Yes

  No

  N/A

• PA10-2<br>Is there a 'Continence' support plan in place?

  Yes

  No

  N/A

Support with medication

• PA11-1<br>Has the Medication risk assessment been completed?

  Yes

  No

  N/A

• PA11-2<br>Is there a medication support plan in place?

  Yes

  No

  N/A

• PA11-3<br>Are PRN protocols in place and completed in full?

  Yes

  No

  N/A

• PA11-4<br>Is the resident allergy status documented on the MAR front sheet and MAR charts or eMAR?

  Yes

  No

  N/A

Support with sleep and rest

• PA12-1<br>Has the daily routines plan been completed in full?

  Yes

  No

  N/A

Consent and capacity

• PA13-1<br>Consent forms are in place and signed by the resident or their legal representative?

  Yes

  No

  N/A

• PA13-2<br>Has a DoLS application been submitted? (If applicable)

  Yes

  No

  N/A

• PA13-3<br>Have Mental Capacity Assessments been completed for restrictive measures? (e.g. bedrails, sensor mats, lap belts etc.)

  Yes

  No

  N/A

• PA13-4<br>Are best interest decisions recorded where Mental Capacity Assessments have concluded that a resident lacks capacity to consent?

  Yes

  No

  N/A